Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN
GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits
for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e.,
name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health
condition and related healthcare services.
Our practice is legally required to maintain the confidentiality of your PHI, and to follow specific rules when using or
disclosing this information. This Notice describes your rights to access and control your PHI. It also describes how we follow
applicable rules when using or disclosing your PHI to provide your treatment, obtain payment for services you receive,
manage our healthcare operations and for other purposes that are permitted or required by law.
Your Rights Under the Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any
questions with our staff.
You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices – We are
required by law to follow the terms of this Notice. We reserve the right to change the terms of the Notice, and to make the
new Notice provisions effective for all PHI that we maintain. We will provide you with a copy of our current Notice if you call
our office and request that a copy be emailed or sent to you in the mail, or ask for one at the time of your next
appointment. The Notice will also be posted in a conspicuous location in our practice, and if such is maintained, on the
practice’s website.
You have the right to authorize other use and disclosure – This means we will only use or disclose your PHI as described in this
Notice, unless you authorize other use or disclosure in writing. For example, we would need your written authorization to use
or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes or substance use disorder
counseling notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the
extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in
the authorization.
You have the right to request an alternative means of confidential communication – This means you have the right to ask us
to contact you about medical matters using an alternative method (i.e., email, fax, telephone), and/or to a destination
designated by you (i.e., cell phone number, alternative address, etc.). You must inform us in writing, using a form provided
by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow
all reasonable requests.
You have the right to inspect and obtain a copy your PHI* – This means you may submit a written request to inspect or obtain
a copy of your complete health record, or to direct us to disclose your PHI to a third party. If your health record is
maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a
reasonable, cost-based fee for paper or electronic copies as established by federal guidelines. We are required to provide
you with access to your records within 30 days of your written request unless an extension is necessary. In such cases, we will
notify you of the reason for the delay, and the expected date when the request will be fulfilled.
You have the right to request a restriction of your PHI* – This means you may ask us, in writing, not to use or disclose any part
of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the
requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your
treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we
restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf,
has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.
You have the right to request an amendment to your protected health information* – This means you may submit a written
request to amend your PHI for as long as we maintain this information. In certain cases, we may deny your request.
You have the right to request a disclosure accountability* – You may submit a written request for a listing of disclosures we
have made of your PHI to entities or persons outside of our practice except for those made upon your request, or for
purposes of treatment, payment or healthcare operations. We will not charge a fee for the first accounting provided in a
12-month period.
You have the right to receive a privacy breach notice – You have the right to receive written notification if the practice
discovers a breach of your unsecured PHI and determines, through a risk assessment, that notification is required.

How We May Use or Disclose Protected Health Information
Following are examples of uses and disclosures of your protected health information that we are permitted to make. These
examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.
Treatment – We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services.
This includes the coordination or management of your healthcare with a third party that is involved in your care and
treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will
also disclose PHI to other healthcare providers who may be involved in your care and treatment.
Payment – Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain
activities that your health insurance plan may undertake before it approves or pays for the healthcare services we
recommend for you such as, making a determination of eligibility or coverage for insurance benefits.
Healthcare Operations – We may use or disclose your PHI as needed to support the business activities of our practice. This
includes, but is not limited to business planning and development, quality assessment and improvement, medical review,
legal services, auditing functions and patient safety activities.
Special Notices – We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We
may contact you by phone or other means to provide results from exams or tests, to provide information that describes or
recommends treatment alternatives regarding your care, or to provide information about health-related benefits and
services offered by our office.
Fundraising – We may contact you regarding fundraising activities, but you will have the right to opt out of receiving further
fundraising communications. Each fundraising notice will include instructions for opting out. In addition, if we intend to use or
disclose your PHI that is subject to 42 CFR Part 2 regulations for fundraising purposes, you will first be provided with a clear
and conspicuous opportunity to elect not to receive any fundraising communications.

Health Information Organization – The practice may elect to use a health information organization, or other such
organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare
operations.
To Others Involved in Your Healthcare – Unless you object, we may disclose to a member of your family, a relative, a close
friend or any other person that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If
you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine,
based on our professional judgment, that it is in your best interest. We may use or disclose PHI to notify or assist in notifying a
family member, personal representative or any other person that is responsible for your care, of your general condition or
death. If you are not present or able to agree or object to the use or disclosure of PHI (e.g., in a disaster relief situation),
then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In
this case, only the PHI that is necessary will be disclosed.
Other Permitted and Required Uses and Disclosures – We are also permitted to use or disclose your PHI without your written
authorization, or providing you an opportunity to object, for the following purposes: if required by state or federal law; for
public health activities and safety issues (e.g. a product recall); for health oversight activities; in cases of abuse, neglect, or
domestic violence; to avert a serious threat to health or safety; for research purposes; in response to a court or
administrative order, and subpoenas that meet certain requirements; to a coroner, medical examiner or funeral director; to
respond to organ and tissue donation requests; to address worker’s compensation, law enforcement and certain other
government requests, and for specialized government functions (e.g., military, national security, etc); with respect to a
group health plan, to disclose information to the health plan sponsor for plan administration; and if requested by the
Department of Health and Human Services in order to investigate or determine our compliance with the requirements of
the Privacy Rule.
Prohibited Uses/Disclosures – Patient records subject to Part 2 regulations may be used or disclosed only as permitted by
Part 2 and HIPAA regulations. Substance use disorder treatment records received from Part 2 programs, or testimony
relaying the contents of such records, will not be used or disclosed in any criminal investigation, to initiate or substantiate
criminal charges, or in civil, criminal, administrative or legislative proceedings by any federal, state, or local authority against
you without your authorization or a court order with accompanying subpoena or similar legal mandate compelling
disclosure.
Redisclosure – Protected health information that is disclosed pursuant to the Privacy Rule may be subject to redisclosure
and no longer protected by the Privacy Rule. For example, if a disclosure is made to a third party who is not subject to
HIPAA rules (e.g., is not a healthcare provider, health plan, or healthcare clearinghouse), this entity may redisclose the PHI
to others without restrictions.

Privacy Complaints
You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you
believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.
* You may ask questions about your privacy rights, file a complaint or submit a written request (for access, restriction, or
amendment of your PHI or to obtain a disclosure accountability) by notifying our Privacy Manager